NSG 6101

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Mr. Barley is a 58-year-old well-developed male with a chief complaint of “a bad cough, mainly in the morning, last winter and this winter.” Cough produces “whitish phlegm”.  The history of present illness includes no complaint of chest pain, weight loss, or fever. There is also no noted nausea, vomiting or diarrhea. Also, of note, the coughing is not precipitated by choking, trembling/shaking, palpitations, sweating or chills.  Mr. Barley notes that he does have contact with chemicals on his farm, however, is cautious to use protective equipment.  He also notes that he has a long (26 year) history of smoking up to two packs of cigarettes per day though recently he has cut back to a half a pack per day. Mr. Barley also notes that he has no known allergies, has not traveled or been exposed to tuberculosis.  He also does not have leg swelling, orthopnea, or proximal nocturnal dyspnea (PND). Mr. Barley has no chronic illness noted in his past, only being seen for minor injuries, and has never been admitted to the hospital and only surgical history is a tonsillectomy at age 12. Mr. Barley takes no medications at this time. Mr. Barley’s social history includes being married for thirty-five years and has two adult daughters. He currently resides with his wife on their farm. Both of his daughters have families of their own. His past family history includes his mother whom he thinks has hypertension, and father who died of a stroke when he was seventy. His sisters and daughters have no known medical history.
To complete a focused physical exam a differential diagnosis must first be established. There are several potential causes of acute dyspnea with a cough including asthma, acute bronchitis, and new onset chronic obstructive pulmonary disease (COPD), lung cancer, and congestive heart failure (CHF).  (Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook, 2017). It is unlikely that Mr. Barley has an active infection due to the lack of fever (current temp 98.9), chills, or change in color and consistency of the phlegm. At this time CHF may be set aside due to the lack of chest pain, edema in lower extremities, the absence of PND, and a blood pressure of 128/78. Therefore, a focused assessment relating to the respiratory system is warranted at this visit.  According to Petty (2001), the National Lung Health Education Program (NLHEP) began a campaign to introduce early assessment, intervention, and diagnosis of chronic lung disease in individuals who smoke.  It was recommended that individuals older than forty-five complete an in-office spirometry exam to indicate risk for chronic lung diseases such as asthma, chronic bronchitis, COPD, and lung cancers.

A general physical exam will assess Mr. Barley’s general appearance, vital signs, head, eyes, ears, nose, throat, neck, lungs, heart, abdomen, and extremities. The focused assessment for COPD will include auscultation of breath sounds specifically looking for wheezing/end expiratory wheezing, assessment of anterior-posterior (AP) diameter of the chest, and prolonged expiratory phase and evidence of a change in the suprasternal notch.  Mr. Barley is noted to have a laryngeal height of 2cm from the sternal notch, increased AP diameter, and diffuse end-expiratory wheezes in addition to self-admittance of long-term smoking.  These findings are indicative of a COPD diagnosis.

The GOLD standard for assessment of COPD is the use of spirometry to assess for airway obstruction. (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2016). Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook (2017) state that additional tests should include pulse oximetry, laboratory studies of complete blood count (CBC) with differential, arterial blood gas (ABG), and alpha 1 antitrypsin, and that imaging including a chest x-ray is suggested. Within the case study, pulmonary function testing (spirometry) is completed indicating that the diagnosis of COPD was accurate.  At this time, I would also have completed baseline blood work including the suggested CBC, ABG, alpha 1 antitrypsin, and imaging of chest x-ray. Though the spirometry exam is the gold standard and indicative of COPD, identifying baseline images and laboratory information will provide information when an exacerbation occurs or the disease progresses.

This diagnosis may be a shock for Mr. Barley and written information will need to be provided about COPD, what changes in symptoms will mean, and the addition of maintenance medications. Studies have shown that patient education and nonpharmacologic interventions are factors which decrease the incidence of COPD emergencies. (Lloyd and Garside, 2017).  It is also necessary to discuss with Mr. Barley the need to quit smoking, assessment of his readiness to quit because smoking is the primary cause of chronic lung disease. (Lloyd and Garside, 2017). Mr. Barley should also be aware that smoking cessation will also decrease his current risk of premature morbidity related to COPD related illnesses. (Petty, 2001).

At this point, it is necessary to support Mr. Barley emotionally as well.  Information about support groups both in person and online should be provided. Resources for additional information about COPD should be supplied as well.

Education on medications including the use of metered dose inhalers (MDI)/inhaled bronchodilators and corticosteroids should also be discussed. It is important to reinforce that no medication will reverse the disease process however, these medications will reduce the severity of the symptoms felt by Mr. Barley. (Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook, 2017). An assessment of Mr. Barley’s current knowledge on how to use MDI’s and preferred learning style is necessary to determine the type of education utilized.  The use of demonstration/ return demonstration was utilized within the case study and is a measurable way to assess assimilated knowledge from teaching. It is also important to discuss with Mr. Barley when to seek medical attention in the future relating to his COPD which includes changes in breathing quality (i.e. increased dyspnea) and productive cough with changes in phlegm amount, color or thickness. (Bostock-Cox, 2017). A preventative measure that Mr. Barley can take is to be sure to stay current on his immunizations including pertussis (DTaP), influenza, and pneumococcus. Seo, Hong, Kim, Choi, Baek, Lee, Song, Lee, Cheong, and Kim (2013) indicate that the influenza vaccine does decrease the risk of COPD exacerbations requiring hospitalization by 27 %. Follow up appointments should be set up to ascertain the effectiveness of the medications and further understanding of Mr. Barley’s diagnosis, perhaps to include his wife and or daughters. Follow up appointments also yield information about depression related to changes in health status as well as an opportunity to assess for weight gain related to corticosteroid use and assessment of smoking cessation.

 

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